Updates on recent legislative and regulatory activity impacting workers' compensation pharmacy
The MyMatrixx by Evernorth Regulatory Affairs team continually tracks and monitors legislation and regulations impacting workers’ compensation pharmacy. Below are some updates on more recent developments. You can follow many of these measures and more with our online tracker.
Indiana bill would allow injured worker choice of physician
Indiana House Bill 1069, introduced December 5, would amend the law to allow the injured worker to choose their attending physician regardless of the date of injury. This reverses course on existing law, which permits employers to choose the injured worker’s attending physician.
Stipulations to HB 1069 include:
- If an injured worker is unable to select or does not select an attending physician yet requires immediate treatment and care, the employer is to select an attending physician to provide immediate treatment/care.
- The employer is to provide or cause to be provided an attending physician during any time that the injured worker has not chosen one.
HB 1069 has been referred to the House Committee on Employment, Labor and Pensions and, if enacted as currently written, will apply after June 30, 2026. Similar bills in Indiana seeking to grant injured worker physician choice have been unsuccessful in prior years/sessions.
Michigan DIFS promotes report on auto reform
As required by law, in early December, the Michigan Department of Insurance and Financial Services (DIFS) released a report, which analyzed the impact of the state’s 2019 auto insurance reform legislation. DIFS publicized the report and the auto insurance cost savings resulting from the reform.
From 2019 to 2024:
- The average auto insurance premium per vehicle in Michigan reduced by $357 (18.8%).
- The average costs to auto insurers of providing auto insurance in the state (includes claims and other associated costs) reduced by $347 (19.3%).
Among the 2019 law reforms, fee schedules were implemented for many healthcare services for the first time. These fee schedules, particularly a percentage-of-2019-charge methodology for items and services without an established Medicare rate, raised concerns of lower provider reimbursement, which could impact access to care. The report, which makes some observations about potential mitigating factors for these concerns, notes that the reform’s impact on access to care and to healthcare providers “is difficult or impossible to comprehensively measure and understand due to data limitations.”
Missouri bills would require workers’ compensation fee schedules
Missouri Senate Bill 1052, pre-filed on December 1 for the 2026 legislative session, would require workers’ compensation fee schedules where none exist today. Current law requires that all fees and charges be “fair and reasonable” and subject to regulation, and a health care provider is not to charge a fee greater than the usual and customary (U&C) fee they receive for the same treatment or service when the payer is a private individual or a private health insurance carrier. SB 1052 would remove that U&C fee language and require the Division of Workers’ Compensation to establish a schedule of fees for “any service” provided pursuant to the workers’ comp law (presumably to include pharmaceutical services). Another pre-filed 2026 bill, Senate Bill 1385, would similarly require establishment of fee schedules.
New Mexico workers’ compensation provider fee schedule and billing instructions updated
The New Mexico Workers’ Compensation Administration (WCA) published adopted updates to its Health Care Provider Fee Schedule & Billing Instructions effective January 1, 2026. The updates will permit payers to use standard Claims Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs), which are already commonly used in Explanation of Benefits (EOBs) and/or Explanation of Reviews (EORs). The CARC and RARC codes will be in addition to the current list of required state-specific EOB codes already adopted by the WCA.
MyMatrixx by Evernorth submitted comments in support of this change earlier this year. As a long-term goal, we also recommended the WCA:
- Consider a reduction in or removal of the remaining state-specific EOB codes
- Work with the International Association of Industrial Accident Boards and Commissions (IAIABC) EDI Medical and ProPay Committee for potential assistance with:
- Reviewing state codes for mapping to standard CARC or RARC codes
- Requesting new CARC or RARC codes if necessary
In response to comments, the WCA said it has initiated outreach to the IAIABC to identify potential crosswalks between its state codes and the standard codes, noting that future fee schedules may see a reduction and potential elimination of state-specific codes.
As part of the adopted changes, language related to labeling resubmitted CMS-1500 bills was adjusted. Other medical fee schedule updates were also made (not impacting pharmacy).
New York workers’ compensation anti-pharmacy network bill vetoed … again
New York Senate No. 4926, a workers’ compensation anti-pharmacy network bill that passed the legislature earlier this year, has been vetoed by New York Governor Kathy Hochul. This bill is similar to S 1974, which also passed but was vetoed by Hochul last year. Like her prior veto, Hochul noted in her S 4926 veto message that the bill would increase litigation, add bureaucratic steps for the New York State Workers’ Compensation Board (WCB), and result in further delays in obtaining needed medication.
Earlier this year the WCB, in attempt to address concerns raised by the bill supporters, amended its regulations to provide a process for out-of-network pharmacy use in situations when there is a non-established body part or condition. Hochul referenced those regulation changes in her veto message.
The MyMatrixx Regulatory Affairs team continues to track legislative and regulatory actions in this area, as we know changes to direction of care may affect the ability of our clients and payers to leverage network pharmacies to control costs, ensure patient safety, and provide access to the appropriate medications for accepted workplace injuries.